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Margaret Smith, 69, often relied on her faith in God when she was ill, as the high costs of medical care kept her away from the doctor's office.

But then she had two strokes. She began visiting a community health center in Prospect Hill operated by Piedmont Health, which, like other clinics of its kind, charges patients based on their income. Smith said she owes her life to the clinic.

“There have been times when maybe my light bill was real high or something, or something unexpected came up, and I had to pay for it — car broke down or whatever — and I didn’t have the money, I just, I won’t go,” she said. “But Prospect Hill has always said, 'Well, come in anyway, if you’re sick you need to come in and see us, we’ll work something out.'

"It’s like a friend helping a friend — they don’t just leave you out there in the cold because you don’t have the money right then and there to pay.”

Community clinics across the country will be forced to cut back next year after Congress failed to pass legislation to extend federal funding to community health centers by a Sept. 30 deadline. Across North Carolina, up to 284,000 patients like Smith could lose access to care, according to estimates from the National Association for Community Health Centers.

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The clinics will take a 70 percent funding cut now that the federal funds have expired, unless Congress passes funding before Thanksgiving.

Because North Carolina didn’t expand Medicaid, the patients at its clinics — 43 percent of whom are uninsured — are in a particularly vulnerable position. Federal funds subsidize the costs for uninsured patients. There are 250 community clinics across the state, including three in Chapel Hill and Carrboro.

“The dollars don’t add up when you’re taking care of an uninsured population,” said Dr. Abigail DeVries, the medical director for Piedmont Health. “We will either have to cut services and or limit the number of uninsured patients that we’re seeing.”

Bipartisan support

Funding for the clinics is included in the Community Health Investment, Modernization and Excellence Act of 2017. While the legislation would fund community health centers until Fiscal Year 2022, it was referred to the U.S. House Committee on Energy and Commerce on Sept. 13, and no further action has been taken.

U.S. Sen. Thom Tillis, R-N.C., signed a bipartisan letter Sept. 19 to the Senate Committee on Health, Education, Labor and Pensions expressing support for the clinics and urging action before the deadline. U.S. Sen. Richard Burr, R-N.C., is on the committee.

Brian Toomey, CEO of Piedmont Health, said some legislators said they won’t vote for the bill until they can figure out how to offset the cost elsewhere.

“We’ve never had a situation where we can only get money for these millions of people if someone shows us where we’re going to get this money from someplace else,” he said.

Ciara Zachary, a policy analyst for the Health Advocacy Project at the progressive NC Justice Center, said the debate over the Affordable Care Act overshadowed the need for reauthorizing the funding.

“Because there was so much of a focus for more of our conservative lawmakers on last-minute attempts to pass the Graham-Cassidy bill or any way to weaken or repeal the ACA and gut Medicaid, I think some of these issues like CHIP or community health centers just got put on the back burner,” she said.

U.S. Rep. David Price, D-N.C., said in a statement that Congress’ failure to reauthorize the funding is “shameful.”

“Republicans in Congress should be focused on prioritizing the health of our nation’s citizens, rather than stripping millions of care and coverage through dangerous budget proposals and reckless efforts to derail the Affordable Care Act,” he said.

What’s at stake

Funding cuts will not officially take effect until the next budget period, but clinics are already making adjustments.

Seventy-two percent of clinics surveyed by the National Association of Community Health Centers said they will institute a hiring freeze, and nearly half said they will reduce staff hours and hours of operation.

“It’s this sort of cloud of uncertainty that we frankly have been dealing with since the ACA debate,” DeVries said. “It’s hard to think ahead when you’re just trying to figure out whether or not you’re going to survive.”

The U.S. Health Resources and Services Administration predicts 9 million patients nationwide will lose coverage, 2,800 sites will be closed and 51,000 providers and staff will be laid off if the funding is not addressed.

In North Carolina, 34 percent of the funding for community health centers comes from federal grants, according to the N.C. Community Health Center Association.

Toomey said Piedmont’s clinics will be forced to stop seeing many uninsured patients.

“The end result is just shifting people from a low-cost, high-quality program like ours and shifting them into emergency rooms and putting more burden of uncompensated care on hospitals,” he said.

The median per-patient cost for a community health center visit is $151, compared to $1,233 for an emergency room visit.

Katherine Restrepo, director of health care policy at the conservative John Locke Foundation, said the community clinics help make health care affordable and price transparent for uninsured and insured patients alike.

“When you have lean resources to work with, you can be more creative and think outside of the box for patients," she said.

Piedmont Health trains 36 third-year medical students from the UNC School of Medicine each year for the family medicine rotation. DeVries said the training costs the clinics more money than they receive from UNC. She said a loss of funding would make it difficult to afford the program.

Bret Robinson, a third-year medical student at UNC completing a clinical rotation with Piedmont Health Services, said the experience has taught him not to judge the patients he's seen — ranging from migrant farmworkers to homeless people — for their decisions.

"The empathy that I have developed and the perspectives I have gained will change the way I approach every single patient interaction," he said.

For Smith, that nonjudgmental attitude is key to her patient experience, and a stark contrast from care she has received elsewhere.

“They treat you with dignity," she said. "They don’t make you feel like a second-class citizen."